NOTE for Physicians: This section provides detailed information for PCN Change Support Staff who will support you to embed SDH in your clinic. Feel free to review it, but don’t worry about the details. Your PCN Practice Coach will work with your clinic to develop an Implementation Plan that addresses your priorities.




PCN Practice Coaches, based on clinic interest, capacity and competency, will include these practices in Implementation Plans and support clinics to achieve them.

1. Behavioral Health –  Behavioral Health Providers in team-based care are key to embedding SDH into your clinic.  Titles for such roles include  Primary Care Social Worker, Behavioralist, Nurse Educator, Primary Care Social Worker, Mental Health Professional (BC listing), etc. They provide specialized skills to better meet the needs of patients with low SES. Other resources to explore include:

2. Learning Culture – Seek out ongoing training opportunities for staff on the impact of poverty on health, cultural safety, trauma, ACEs and other SDH.  Make ACEs & Trauma Informed Practice the first Team Learning session undertaken.

3. Direct Life Skills Supports – Provide dedicated time/resources for a social worker to tackle inequities in a clinical setting through psycho-social assessments and patient support.

4. Treatment Planning – During regular team meetings and QI sessions, work with your team to consider patients’ SES in treatment plans, including:

  • Affordability of medication
  • Ability to attend treatment/therapy sessions due to work commitments (especially for hourly wage workers); childcare; transportation
  • Family and other social support
  • Social prescriptions – to non-medical community resources such as exercise groups, art classes or volunteering 

How is the Team Doing?
Measures of Success

Goal: The team brings, or can access, a comprehensive range of services to address the health, social and economic needs of both the individuals and populations it serves.

  • The composition of the team or network of health professionals fits the specific needs of the community. 
  • The family physician(s) work collaboratively with the other team members to provide a comprehensive, coordinated range of services for people of all ages, including the management of undifferentiated illness and complex medical presentation.
  • The practice addresses the health needs of both the individuals and populations it serves, incorporating the health impact of social determinants such as poverty, job loss, culture, gender and homelessness.